Failure to Complete Post-Fall Assessments and Notify Physician for High-Risk Resident on Anticoagulant
Penalty
Summary
The facility failed to provide a safe environment and appropriate care services for a resident with a high risk of falls and on anticoagulant therapy. The resident, an elderly male with a history of atrial fibrillation and generalized weakness, experienced three falls within a short period. Despite a documented high fall risk and care plan interventions requiring ambulation with assistance and careful handling due to anticoagulant use, the facility did not complete post-fall reassessments or update the care plan after each incident as required by policy. Additionally, the facility did not notify the resident's physician after the second and third falls, nor did they communicate the resident's use of heparin, a blood thinner, which increased the risk of bleeding complications. Interviews with nursing staff revealed a lack of communication regarding the resident's medication status and the absence of physician notification following multiple falls. The physician confirmed not being informed about the resident's anticoagulant use or the subsequent falls, which could have influenced clinical decisions. Record reviews showed no evidence of post-fall assessments or care plan revisions after each fall, and the Director of Nursing was unaware of the required post-fall assessment form referenced in facility policy. The facility's policies required significant information, such as changes in condition and fall incidents, to be reported to the attending physician and documented in the clinical record, which was not done in this case. The resident was later found unresponsive and pronounced deceased the morning after the falls.